Minding the gap: towards a shared clinical reasoning lexicon across the pre-clerkship/clerkship transition

ABSTRACT

Teaching and learning of clinical reasoning are core principles of medical education. However, little guidance exists for faculty leaders to navigate curricular transitions between pre-clerkship and clerkship curricular phases. This study compares how educational leaders in these two phases understand clinical reasoning instruction. Previously reported cross-sectional surveys of pre-clerkship clinical skills course directors, and clerkship leaders were compared. Comparisons focused on perceived importance of a number of core clinical reasoning concepts, barriers to clinical reasoning instruction, level of familiarity across the undergraduate medical curriculum, and inclusion of clinical reasoning instruction in each area of the curriculum. Analyses were performed using the Mann Whitney U test. Both sets of leaders rated lack of curricular time as the largest barrier to teaching clinical reasoning. Clerkship leaders also noted a lack of faculty with skills to teach clinical reasoning concepts as a significant barrier (p < 0.02), while pre-clerkship leaders were more likely to perceive that these concepts were too advanced for their students (p < 0.001). Pre-clerkship leaders reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (p < 0.001). As faculty transition students from the pre-clerkship to the clerkship phase, a shared understanding of what is taught and when, accompanied by successful faculty development, may aid the development of longitudinal, milestone-based clinical reasoning instruction.

KEYWORDS:

• Clinical reasoning
• UME
• preclerkship
• clerkship
• clinical skills
• transition

Introduction

Clinical reasoning is considered to be a physician’s most critical competency [1]. It is defined as ‘the cognitive and non-cognitive process by which a healthcare professional consciously or unconsciously interacts with the patient and the environment to collect and interpret patient data, weighs the benefits and risks of action, and understands patient preferences to determine a working diagnostic and therapeutic management plan whose purpose is to improve a patient’s well-being.’ [2,3] Previous studies have shown that errors in clinical reasoning, including unreliable data gathering and inaccurate data synthesis, are major drivers of diagnostic errors [4]. Given the significant effects of diagnostic error on patient outcomes and safety, experts have called for clinical reasoning instruction to be emphasized across the medical education continuum [5] and added as the seventh Accreditation Council for Graduate Medical Education (ACGME) core competency [1]. While it is important to ensure that clinical reasoning is addressed at each training stage, developing effective longitudinal instruction also includes attention to major educational transition points that are recognized as challenging for medical trainees [6–8].

A recommendation of the Undergraduate Medical Education-Graduate Medical Education Review Committee (UGRC), tasked to improve the UME-to-GME transition, is to define and implement a common framework and competencies [9]. The AAMC leadership identified the transition between pre-clerkship to clerkship education as the first UME transition point [10]. A scoping review of entry into clinical clerkships [11] recognized that medical education researchers conducted studies on this first transition from three conceptual perspectives: educational; social, and developmental [11]. Most studies applied an educational perspective, aiming to merely increase preparedness of students’ knowledge and skill which led to a maladaptive struggle. Researchers using a developmental perspective however recognized that early learners consistently face challenges when transitioning from preclinical to clinical training and aimed to empower students by optimizing transferable learning strategies and facilitating reflection [11]. Although elements of clinical reasoning education are mandatory for medical school curricula, [12] limited data on how early clinical reasoning skills and concepts are taught developmentally, with studies limited to individual concepts, single specialty or single institution case studies [13,14].

This led to a collaboration between the Directors of Clinical Skills Education (DOCS), a consortium of educators who direct clinical skills education in the pre-clerkship curriculum, and the Alliance for Clinical Education (ACE), an organization encompassing members from clerkship specialty organizations. Both surveyed their members to characterize the current state of clinical reasoning education in their respective UME phase [15,16]. This study examined these data through the lens of the first UME transition. We aimed to explore how longitudinal clinical reasoning instruction is approached. We sought to compare how educational leaders in these two phases ascribe importance to teaching clinical reasoning concepts in each aspect of the curriculum, to identify which concepts they teach, their respective awareness of clinical reasoning instruction in the other curricular phase, and their perceptions of barriers to clinical reasoning instruction. Exploring this competency from an early vantage point in medical education may contribute to an overall UME-GME framework for clinical reasoning.

Materials and methods

Study design, setting, and participants

The authors previously reported separately on cross-sectional surveys of pre-clerkship clinical skills course directors serving as institutional representatives to the DOCS organization, and clerkship leaders (clerkship directors and co-directors, associate clerkship directors, and clerkship clinical site directors) from organizations that comprise ACE [15,16]. This report represents the analysis comparing the results from these two surveys.

Our research team consisted of a group of DOCS members collaborating as part of a clinical reasoning curriculum working group and a group of clerkship directors and faculty interested in clinical reasoning education who were recruited through ACE. This group worked together to develop a common survey based on Rencic and Trowbridge’s survey in their 2017 study [17]. This common survey was then modified slightly to match the specific settings of each group of participants and the two surveys were administered in parallel. The survey to DOCS institutional representatives was administered via Survey Monkey with four rounds of contacting prospective participants. The survey to ACE clerkship leaders was administered in two different ways. Those member organizations that had regular surveys of their member organizations (COMSEP, CDIM and ADMSEP) included the questions from our survey within their existing survey structure. Other member organizations (ASE, APGO, CDEM, STFM, AAN) included an invitation to participate in the survey on their respective listserv; this invitation was delivered on three occasions.

Data analysis

To facilitate comparison of pre-clerkship clinical skills directors’ responses to clerkship leaders’ responses, we used a shared spreadsheet (Google, Mountain View, CA) and converted responses from Likert scale items to numeric scores in which not at all important = 1, moderately or somewhat important = 2, and extremely important = 3. We used the Mann-Whitney U test to investigate the differences in the mean scores between pre-clerkship and clerkship leaders’ data for each question item response. We defined p values less than 0.05 to indicate statistical significance. We reported mean and standard deviation, as well as median and range for our readers’ convenience. We made comparisons for survey items related to perceived importance ascribed to each clinical reasoning concept, perceptions about barriers to clinical reasoning instruction, and degree of familiarity with the clinical reasoning curriculum in the other’s phase of UME. We used SPSS version 26 software (IBM Corp, Armonk, NY) to perform the descriptive and inferential analyses.

We also examined the degree of inclusion of clinical reasoning concepts in each curricular phase (Table 1) but given differences in the structure and survey anchors for the parallel questionnaire items, we did not make direct statistical comparisons. We compared responses to these items by examining general patterns.

Table 1. Clinical reasoning concepts included in the survey (from Gold et al., PLOS one, 17(8): e0273250).

Clinical Reasoning Concept	Definition	Example(s)
Semantic qualifier	Abstract, often binary terms that help narrow or specify the meaning of a symptom, sign, pathologic process or disease	Acute vs. chronic, moderate vs. severe, or unilateral vs. bilateral
Problem representation	Clinician’s synthesis of key discriminating aspects of the history, exam, and data; often expressed as a summary statement)	60 year-old male man with history of type 2 diabetes and hypertension with acute onset of left-sided chest pain and diaphoresis
Illness scripts	Clinician’s mental representations of clinical findings, underlying pathology, diagnostic and treatment approaches, and prognosis associated with diseases	The representative findings for croup are: age 18 months to 3 years-old with barky cough, and stridor, and presentation from October to March
Dual processing theory	Description of cognitive processes as the interplay of non-analytic and analytical reasoning approaches, described as System 1 (fast, pattern recognition, experience-based) vs. System 2 (slow, deliberate, rational)	An expert sees a swollen calf in a post-op patient and diagnoses a DVT (system 1). A novice learner looks at a swollen leg and needs to consider a variety of causes, associated with pathophysiology to consider DVT as a diagnosis (system 2).
Heuristics	Mental shortcuts or rules of thumb used subconsciously in approaching a problem	A physician immediately thinks of influenza in a patient presenting with fever during flu season
Bayesian reasoning	Calculating the post-test probability using the pre-test probability and the likelihood ratio.	With a pretest probability of 25% for pulmonary embolus and a negative D-dimer test with a LR of 0.1, the post-test probability of PE is 3%
Cognitive bias	Dispositions or preferences that can affect judgments and decisions in a subconscious manner	Narrowly focusing on a single feature (sore throat) to support the diagnostic hypothesis (e.g., Strep pharyngitis), even if other or new information refutes it (cough, lack of exudate, lack of fever)

Ethics

This study was reviewed and deemed exempt by the Institutional Review Boards at Michigan State University, Dartmouth College, the University of Utah, and the Alliance for Academic Internal Medicine (AAIM).

Results

Response rates and demographics

The DOCS institutional representative response rate was 69% (102/148) of targeted respondents answering 1 or more survey items. More detailed respondent demographics have been previously reported [15]. This overall response rate for the clerkship leaders survey was 19% (305/1859) and ranged from 3% to 30% across specialties. Approximately 72% (220/305) percent of ACE respondents were clerkship leaders [16].

Importance ascribed to clinical reasoning concepts

With respect to the importance of teaching seven core clinical reasoning concepts to pre- clerkship students, pre-clerkship course directors rated each concept as more important than clerkship leaders. These differences were statistically significant for all concepts, with the exception of Bayesian reasoning (p < 0.05, Table 2). When asked about how important it was to teach these concepts to clerkship students, pre-clerkship course directors again rated each of the clinical reasoning concepts as more important than clerkship leaders (p < 0.001, Table 3).

Table 2. Importance of teaching clinical reasoning concepts in pre-clerkship clinical courses as rated by pre-clerkship clinical course directors and clerkship leaders (1-not at all important, 2-moderately or somewhat important, 3-extremely important).

	Pre-Clerkship Mean (SD) N	Pre-Clerkship Median (range)	Clerkship Mean (SD) N	Clerkship Median (range)	P value
Use of semantic qualifiers	2.72 (0.49) 100	3 (2)	2.37 (0.72) 208	2 (3)	<0.001
Use of problem representations	2.87 (0.42) 100	3 (3)	2.48 (0.69) 207	3 (3)	<0.001
Use of illness scripts	2.60 (0.62) 99	3 (3)	2.37 (0.73) 206	2 (3)	0.01
Dual-processing theory	2.38 (0.72) 100	2.5 (3)	1.86 (0.98) 207	2 (3)	<0.001
Use and limitations of heuristics	2.33 (0.70) 100	2 (3)	2.02 (0.86) 207	2 (3)	0.003
Use of Bayesian reasoning	2.27 (0.62) 100	2 (3)	2.16 (0.89) 207	2 (3)	0.84
Cognitive bias	2.69 (0.56) 100	3 (3)	2.28 (0.81) 208	2 (3)	<0.001

Table 3. Importance of teaching clinical reasoning concepts in clerkships as rated by pre-clerkship clinical course directors and clerkship leaders (1-not at all important, 2- moderately or somewhat important, 3-extremely important).

	Pre-Clerkship Mean (SD) N	Pre-Clerkship Median (range)	Clerkship Mean (SD) N	Clerkship Median (range)	P value
Use of semantic qualifiers	2.88 (0.42) 90	3 (3)	2.36 (0.73) 211	2 (3)	<0.001
Use of problem representations	2.88 (0.49) 91	3 (3)	2.69 (0.60) 211	3 (3)	<0.001
Use of illness scripts	2.81 (0.60) 91	3 (3)	2.62 (0.58) 211	3 (3)	<0.001
Dual-processing theory	2.64 (0.69) 91	3 (3)	2.04 (0.87) 211	2 (3)	<0.001
Use and limitations of heuristics	2.76 (0.58) 91	3 (3)	2.20 (0.77) 208	2 (3)	<0.001
Use of Bayesian reasoning	2.71 (0.56) 91	3 (3)	2.04 (0.88) 210	2 (3)	<0.001
Cognitive bias	2.84 (0.52) 91	3 (3)	2.51 (0.67) 209	3 (3)	<0.001

Barriers to clinical reasoning instruction

When asked about barriers to clinical reasoning instruction in their respective phases of the curriculum, both pre-clerkship course directors and clerkship leaders rated lack of curricular time as the largest barrier, followed by lack of faculty with skills to teach clinical reasoning (Table 4). There was a statistically significant difference in how pre-clerkship and clerkship respondents viewed ‘perceptions that clinical reasoning concepts are too advanced for students’ with pre-clerkship respondents indicating this as a larger barrier in their portion of the curriculum compared to clerkship leaders (p < 0.001). There was also a statistically significant difference in how pre-clerkship and clerkship respondents viewed ‘lack of faculty with skills to teach clinical reasoning concepts’ with clerkship leaders, indicating this as a larger barrier in their portion of the curriculum compared to pre-clerkship respondents (p < 0.02).

Table 4. Pre-clerkship clinical skills course director and clerkship leader perceptions about the degree to which specific barriers impede the inclusion of clinical reasoning activities in their respective phases of medical school curricula (pre-clinical course and clerkship curricula) (1-not at all an impediment, 2-somewhat of an impediment, 3-a major impediment).

	Pre-Clerkship Mean (SD) N = 94	Pre-Clerkship Median (range)	Clerkship Mean (SD) N = 208	Clerkship Median (range)	P value
Lack of curricular time to add clinical reasoning content	2.15 (0.69)	2 (2)	2.13 (0.68)	2 (2)	0.86
Perception that clinical reasoning concepts cannot be taught	1.23 (0.50)	1 (2)	1.30 (0.51)	1 (2)	0.18
Perception that clinical reasoning concepts are too advanced for pre- clerkship/clerkship students (respectively)	1.54 (0.56)	2 (2)	1.25 (0.48)	1 (2)	<0.001
Lack of faculty with skills to teach clinical reasoning concepts	1.87 (0.74)	2 (2)	2.09 (0.77)	2 (2)	0.02

Level of familiarity with clinical reasoning instruction across the curriculum

Pre-clerkship clinical skills course directors were asked about their level of familiarity with clinical reasoning instruction in the clerkship curriculum and clerkship leaders were asked about their level of familiarity with clinical reasoning instruction in the pre-clerkship curriculum. Responses were recorded on a three- point Likert scale format (not at all familiar = 1, somewhat familiar = 2, extremely familiar = 3). Pre-clerkship clinical skills course directors reported a higher level of familiarity with the clerkship curriculum than clerkship leaders reported of the pre-clerkship curriculum (median 2 vs 1, mean 2.1 vs 1.8 respectively, p < 0.001).

Inclusion of clinical reasoning instruction

When asked about inclusion of clinical reasoning instruction within their respective curricula, each clinical reasoning concept was indicated as moderately to extensively included in their curricula by the majority of pre-clerkship respondents (Table 5). Only semantic qualifiers, problem representation, cognitive bias, and illness scripts were indicated as included in their courses by the majority of clerkship respondents (Table 5). Notably, the concepts of dual-process theory, heuristics, and Bayesian reasoning were most frequently noted by both pre-clerkship clinical skills directors and clerkship leaders to be absent from their respective curricula.

Table 5. Inclusion of clinical reasoning concepts in pre-clerkship clinical courses and clerkships as rated by pre-clerkship clinical course directors (n = 94) and clerkship affiliated faculty (n = 305), respectively.

	Pre-clerkship clinical skills course directors (N = 94)				Clerkship leaders (N = 217)
Concept	Not familiar with concept % (N)	Not at all included % (N)	Moderately included % (N)	Extensively included % (N)	Not sure or unfamiliar % (N)	Not covered in the overall clerkships curriculum% (N)	Covered elsewhere in the clerkships curriculum but not in my clerkship % (N)		Covered in my clerkship % (N)
Semantic Qualifiers	2% (2)	7% (7)	52% (49)	38% (36)	11.1% (24)	11.6% (25)	15.2% (33)		62.0% (134)
Problem Representations	1% (1)	1% (1)	36% (34)	62% (58)	8.8% (19)	5.1% (11)	10.1% (22)		76.4% (165)
Illness scripts	1% (1)	9% (8)	48% (45)	43% (40)	8.8% (19)	8.8% (19)	18.5% (40)		63.9% (138)
Dual processing theory	1% (1)	24% (23)	54% (51)	21% (20)	27.1% (59)	22.1% (50)	20.6% (45)		29.4 (54)
Heuristics	1% (1)	29% (27)	54% (51)	48% (15)	22.2% (48)	15.7% (34)	31.5% (68)		39.4% (85)
Bayesian Reasoning	0% (0)	29% (27)	48% (45)	23% (22)	15.7% (34)	31.5% (68)	31.5% (68)		32.9% (71)
Cognitive bias	0% (0)	12% (11)	49% (46)	39% (37)	18.1% (39)	11.6% (25)	18.1% (39)		52.3% (113)

Discussion

The present study aimed to characterize educational leaders’ perspectives on clinical reasoning curricula across the clinical and preclinical phases of UME, so that curricular design can be enriched within and across the two phases. We identified three themes as we interpreted the data: teachable clinical reasoning concepts; the need for a continuum of instruction; and prioritizing clinical reasoning instruction within the curriculum.

Teachable clinical reasoning concepts

Both pre-clerkship and clerkship faculty survey participants rated task-oriented concepts such as problem representation, semantic qualifiers, and illness scripts as highly important to teach and more often included in their curricula, where as metacognitive concepts such as Bayesian reasoning, dual process theory, and the use and limitations of heuristics were rated as less important and also less likely to be included in their curricula.

These findings align with the literature. In 2021, Cooper et al. identified twenty-seven studies that described teaching methodologies used for clinical reasoning education in UME [5]. The studies that used a task-oriented approach to teach clinical reasoning skills, including illness scripts, structured reflection, thinking out loud, and practicing cases with feedback showed improved student performance. The review highlighted that there is little evidence to demonstrate that teaching about thinking per se improves diagnostic performance [18,19]. They concluded that clinical reasoning curricula that only included principles of decision making and cognitive debiasing strategies did not improve overall student performance. In contrast, Schmidt and Mameda found that students who learned via teaching methodologies geared towards building knowledge and understanding showed improvements in clinical reasoning skills, whereas learners taught the general thinking process to improve clinical reasoning were disadvantaged [20].

The need for a continuum of clinical reasoning instruction

Learners’ perception of minimal alignment in education from one stage to the next has been described in the literature [8]. Our study observed that pre-clerkship course directors had a greater level of familiarity with the clerkship curriculum than clerkship leaders had of the pre-clerkship curriculum (Table 5), the average level of familiarity with the other phase of the curriculum was only approximately ‘somewhat’ familiar for both pre-clerkship and clerkship faculty. This disconnect can contribute to a siloed and fragmented approach to clinical reasoning instruction.

A key tenet of effective competency-based medical education (CBME) is a seamless educational continuum that is vertically integrated and developmental, whereby concepts are introduced early and then reinforced and expanded upon in later years [21]. This conceptual perspective, used to approach the transition from preclinical to clinical training, encompasses the educational and developmental perspectives outlined by Atherley et al. [11] with an aim to empower students by optimizing transferable learning strategies. The need for coordinated clinical reasoning curricula is not unique to US medical schools. A recent consensus statement, published by the group on Clinical Reasoning in Medical Education (CReME) of the United Kingdom, included a charge to implement an explicit, longitudinal, and developmental clinical reasoning curriculum across UME. These authors emphasized that ‘careful attention to what is taught, how it is taught, and when it is taught can facilitate clinical reasoning development more effectively, through purposeful curriculum design.’ [5] Therefore, communication and collaboration between preclerkship and clerkship leaders should be prioritized when designing clinical reasoning curricula.

Only a minority of schools reported having CR focused teaching sessions [22]. Rowat et al. designed and implemented a three-phase formal longitudinal four-year clinical reasoning curriculum, with a special emphasis on introducing concepts in the preclinical years. Their study demonstrated that a longitudinal patient-centered curriculum that integrates pathophysiology, social determinants of health and clinical skills, is feasible for the acquisition and application of these skills. Early introduction of CR concepts showed improvement in student reasoning skills post-intervention [22].

Prioritizing clinical reasoning instruction

Attempting to narrow the gap between preclinical and clinical education through curricular innovations and transferable learning strategies can facilitate knowledge and skill development and reduce students’ struggles at this critical transition [11]. However, skill development takes time, and we identified that the most commonly cited barrier to inclusion of clinical reasoning content in both pre-clerkship and clerkship curricula was lack of curricular time (Table 4), suggesting that clinical reasoning instruction may be losing to other priorities in curricular design. Both surveys also reported a lack of faculty to teach clinical reasoning as a significant barrier to instruction. This may be a reflection of the many competing demands placed on faculty in academic medicine, particularly clinical faculty who are typically charged with clinical skills instruction during active clinical practice. Access to teaching faculty may be more of a barrier for clerkship leaders because their prospective educator pools are likely limited to faculty in their respective departments and may include community faculty with limited protected teaching time. By contrast, pre-clerkship clinical skills directors can draw from a larger faculty pool across several departments. For some respondents, ‘lack of faculty to teach clinical reasoning’ may result from a limited pool of faculty with expertise in clinical reasoning.

Lack of qualified faculty to teach clinical reasoning, lack of faculty teaching time, lack of curricular time, and lack of time to participate in faculty training, align with several of the perceived barriers identified in a multicenter interview study of European health professions educators [23]. Together these findings highlight the importance of implementing a faculty development program that incorporates what is expected of learners in each phase of the curriculum and how best to identify and address clinical reasoning deficiencies, while committing curricular and faculty time to achieve this. Indeed, a few faculty development workshops and curricula have been published to address this gap [24,25]. However, whereas faculty development is valuable for educators at all stages of medical education, a shared mental model with a common clinical reasoning lexicon and curriculum that crosses developmental stages, disciplines, and clinical sites may be transformative [26].

Limitations

We acknowledge several limitations to this data. The response rate from the pre-clerkship course directors was robust, however the low response rate of the clerkship directors may limit the generalizability of these results. Additionally, the surgical clerkship organization didn’t respond to survey invitations and the psychiatry clerkship organization modified the survey, making direct comparisons impossible. Therefore, a substantial portion of the clerkship data, surgery and psychiatry, were excluded from the ACE dataset. Nonetheless, we thought it was important to include all of the clerkship organizations’ data to represent the broad range of responses from clerkship leaders rather than limit our data to only those groups that had regular surveys.

Although these surveys provide some reassurance that both pre-clerkship and clerkship faculty are familiar with clinical reasoning content across the continuum, it is possible that ACE respondents are aware primarily of content within their own clerkships rather than across all clerkships at their institution, resulting in an underestimate of the degree to which these concepts are covered in the clerkship curriculum.

The terminology used in these surveys to describe clinical reasoning concepts may not be shared between all institutions, or between pre-clerkship and clerkship faculty, which may have resulted in misclassification. As noted in the literature, clinical reasoning is described with a heterogenous lexicon [26,27]. However, most respondents in both the surveys reported that they are familiar with the concepts described, considering specific examples were given for each concept within the surveys.

Finally, the survey respondents included only clinical skills directors and clerkship leaders. Other curricular leaders who were not surveyed may have different approaches to the teaching and assessment of clinical reasoning.

This study has examined the perspectives of pre-clerkship and clerkship faculty but not that of students. Future studies might explore the actual competence of students in clinical reasoning across the UME spectrum.

Conclusion

Our findings indicate that both clerkship and pre-clerkship faculty agree that most clinical reasoning concepts are important to teach but barriers exist to optimal curricular delivery. There seems to be a shared inference among UME educators that the priorities for clinical reasoning instruction vary across both phases of UME, which could be the foundation for recommending national standards for a developmentally sequenced clinical reasoning curriculum. The recent introduction of clinical reasoning milestones through the ACGME Milestones 2.0 may provide additional data to inform opportunities in UME for clinical reasoning education through backward design.

To reinforce successful implementation of an explicitly theory-informed, longitudinal and developmental approach to teaching and assessing clinical reasoning across this early transition, a commitment to deliberate and shared curricula is needed to inform both policy and best practices [21,22,28]. While pre-clerkship clinical reasoning curricula have become standard in many medical schools [3], it is imperative that clinical reasoning instruction continue across all specialties, considering clinical reasoning is content- and context-specific [13,14]. Insight from pre-clerkship and clerkship leaders on assumptions and expectations of an incoming clerk, and explicit communication between the two groups, may further bridge curricular design and provide appropriate scaffolding of knowledge, skills, and attitudes needed for success in clerkships. We also recognize the essential need for all educators to use a shared clinical reasoning lexicon, to facilitate effective communication and collaboration among educators, and for learners to recognize the developmental progression of clinical reasoning skills. Additionally, we recommend that faculty receive rigorous training in the developmental needs of learners’ cognitive and non-cognitive load for clinical reasoning teaching and assessment.

The lack of a seamless transition of clinical reasoning education can hinder a student’s clinical development and social acclimation to the clinical environment [5]. The authors posit that bridging this divide, by ensuring that educators from both phases of UME collaboratively use a transition framework to design a longitudinal and developmental clinical reasoning curriculum that encompasses an educational, social, and developmental conceptual perspective, may lead to a more fluid transition and stimulate opportunities to advance students’ adaptations to the clinical environment.

Author contributions

All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Ethical approval

Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013). This study was reviewed and deemed exempt by the Institutional Review Boards at Michigan State University, Dartmouth College, the University of Utah, and the Alliance for Academic Internal Medicine (AAIM).

Informed consent

Informed consent was obtained from all individuals included in this study.

Acknowledgments

The authors wish to thank the DOCS members, and members of the clerkship organizations that comprise ACE: the Association of Directors of Medical Student Education in Psychiatry (ADMSEP), the Association of Professors of Gynecology and Obstetrics (APGO), the Clerkship Directors in Emergency Medicine (CDEM), the Clerkship Directors in Internal Medicine (CDIM), the Council on Medical Student Education in Pediatrics (COMSEP), the Consortium of Neurology Clerkship Directors (CNCD) and the Society of Teachers of Family Medicine (STFM), who participated in this survey study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary Material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2024.2307715

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.